Author Topic: Which benefit period applies?  (Read 2324 times)

Sophrosyne

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Which benefit period applies?
« on: February 27, 2012, 12:07:54 PM »
I've learned an interesting thing today--apparently Value Options decides which benefit period a claim applies to by the date the claim was received, not the date of service on the claim. To be more specific:
Patient has met 2011 OOP, all claims payable at 100% of allowed amount. We file a claim for date of service 12/21/2011. Value Options receives the claim on 01/09/2012 and proceeds to apply it to the 2012 benefits.
Can this be correct?!?! I thought it was always by date of service, not by the date the company received the claim. CONFUSED. Any thoughts?

DMK

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Re: Which benefit period applies?
« Reply #1 on: February 27, 2012, 12:16:58 PM »
If the patient's policy is by CALENDAR year, the date of service should be applied to the benefit year of the date of service.  You may need to verify that their benefits don't renew in an odd month.  We have many teachers who renew on 7/1 of each year, not Jan. 1.  A phone call should get your question answered.

PMRNC

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Re: Which benefit period applies?
« Reply #2 on: February 27, 2012, 04:17:08 PM »
Quote
If the patient's policy is by CALENDAR year, the date of service should be applied to the benefit year of the date of service.  You may need to verify that their benefits don't renew in an odd month.  We have many teachers who renew on 7/1 of each year, not Jan. 1.  A phone call should get your question answered.

That's correct. My plan goes from Nov 1. 
Linda Walker
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Sophrosyne

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Re: Which benefit period applies?
« Reply #3 on: February 28, 2012, 01:50:40 PM »
The Value Options rep I spoke with verified that the policy was a calendar year policy. She just said that VO applies the claim to a benefit period based on the day VO received the claim, not the date of service. So, according to this rep, date of service 12/21/11 counts towards the 2012 policy because they received in in 2012.
I have NEVER heard of anything like this before. Is this something VO can do? It seems very wrong to me, but that's hardly any leverage to go on.
Thanks all.

PMRNC

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Re: Which benefit period applies?
« Reply #4 on: February 28, 2012, 06:48:12 PM »
Quote
The Value Options rep I spoke with verified that the policy was a calendar year policy. She just said that VO applies the claim to a benefit period based on the day VO received the claim, not the date of service. So, according to this rep, date of service 12/21/11 counts towards the 2012 policy because they received in in 2012.
I have NEVER heard of anything like this before. Is this something VO can do? It seems very wrong to me, but that's hardly any leverage to go on.
Thanks all.

She either explained it wrong OR you misunderstood. MOST calendar year plan's have what's called carry-over months for deductibles/coinsurance, those carry over months are October, Nov, Dec.  If a patient had Not met their deductible by those months, the amount going to deductible would not only go to satisfy 2011's deductible but also 2012. So for example a patient has a visit of $200 on 12/1/2011. They had not met their deductible of let's say $100. $100 will be used to satisfy 2011 deductible AND it will also be applied to 2012's deductible.  So I'm thinking the rep may NOT have explained it correctly.  Now if they satisfied 2011 deductible but they are deducting deductible for 2012, that does not sound right.  If they are however counting the visit towards the benefit visit max for 2012 that's ok, yes carriers can use date of receipt of claim, at the end of the year if they exhaust the benefit, they may cancel out the prior year visit or two. 
Linda Walker
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www.billerswebsite.com

Sophrosyne

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Re: Which benefit period applies?
« Reply #5 on: March 01, 2012, 08:23:19 AM »
More specifically this is the case: the patient owes $15 co-pay. However, the patient had met her 2011 OOP in July of 2011. VO had for months (from July to December) been paying at 100% and all EOBs stated that the patient owed nothing. EXCEPT for her last visit in 2011--date of service 12/21/2011. Because VO received the claim on 01/09/2012, DOS 12/21/2011 was applied to the 2012 benefits (in which the patient has not yet met her OOP). Thus, the patient owes the $15 co-pay (according to this rep).

Quote
If they are however counting the visit towards the benefit visit max for 2012 that's ok, yes carriers can use date of receipt of claim, at the end of the year if they exhaust the benefit, they may cancel out the prior year visit or two. 

I didn't quite understand this bit. Are you saying if the patient exhausted her 2011 visit limit, the carrier could use date of receipt of the claim to apply it to the 2012 visit limit? Cause that would be fine with me if this were the case!  ;D  However, in this case, the patient has unlimited visits (for both 2011 and 2012), so I don't think this is the issue here.

There's supposed to be a VO supervisor calling me sometime this week, so I'll let y'all know what she says! Thanks!

Michele

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Re: Which benefit period applies?
« Reply #6 on: March 01, 2012, 08:50:06 AM »
I agree.  She either explained it wrong or she just plain HAD it wrong.  If the policy is a calender year policy from 1/1 - 12/31 they cannot choose to apply one years service to another year based on receipt date.  Like Linda said, maybe they have 'last quarter carryover' or something but from what you've described they met their oop in 2011 so that wouldn't apply.  I would call and get a different person and argue the point.
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PMRNC

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Re: Which benefit period applies?
« Reply #7 on: March 01, 2012, 09:13:57 AM »
I have to agree, I would call and speak with someone else.. i will say this from working at a few carriers... IF that claim was processed using automatic plan calculation, their software is almost error / bullet proof.. a manual calculation would indicate an error on the processing end..but of course you wouldn't know that unless you processed claims.  I'm ONLY guessing that based on that fact, the plan is NOT a calendar year plan and the rep explained something the wrong way.
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com